“Should I Say Something?”: A Simulation Curriculum on Addressing Lapses in Professionalism to Improve Patient Safety

Introduction Medical students may witness lapses in professionalism but lack tools to effectively address such episodes. Current professionalism curricula lack opportunities to practice communication skills in addressing professionalism lapses. Methods We designed a simulation curriculum to introduce professionalism expectations, provide communication tools using elements of the Agency for Healthcare Research and Quality TeamSTEPPS program, and address observed professionalism lapses involving patient safety in hierarchical patient care teams. Students were surveyed on knowledge, skills, and attitude regarding professionalism before, immediately after, and 6 months after participation. Results Of 253 students, 70 (28%) completed baseline and immediate postsurveys, and 39 (15%) completed all surveys. In immediate postsurveys, knowledge of communication tools (82% to 94%, p = .003) and empowerment to address residents (19% to 44%, p = .001) and attendings (15% to 39%, p < .001) increased. At 6 months, 96% of students reported witnessing a professionalism lapse. Discussion The curriculum was successful in reported gains in knowledge of communication tools and empowerment to address professionalism lapses, but few students reported using the techniques to address witnessed lapses in real life.


Introduction
Lapses in professionalism affect patient safety, adverse outcomes, and medical errors and contribute to adverse learning environments. 1,2Learners report witnessing unprofessional behaviors more often than traditional patient safety concerns (such as medication errors) but recount speaking up about professionalism issues less frequently, identifying fear of conflict as a barrier. 3Learners also report lacking the skills and knowledge to address their concerns about professionalism lapses. 4Learners are less likely to speak up when a professionalism lapse is committed by an attending physician and more likely to speak up in an environment perceived as being supportive, safe, and one in which teamwork and patient safety are valued. 3,5Instruction in professionalism skills and behaviors before students' clinical responsibilities start has longterm benefits, as it is associated with decreased unprofessional behavior in later careers. 6However, opportunities to learn and practice strategies to address conflict and unprofessional behavior are limited in the standard medical curriculum.To date, there is no standardized approach or recommended timing in the medical school curriculum for teaching professionalism or approaches to address observed lapses in professionalism, and curricula reported in the literature are aimed at remediation of unprofessional behaviors, not prevention. 7,80][11][12] Once in the clinical learning environment, learners occupy a vulnerable place in the hierarchy of health care teams.While they are expected to behave professionally and engage in safe patient care, learners feel they are continuously being evaluated and may be reluctant to speak up.Unfamiliarity with health care team member roles, frequent changes in team members, and dependence on supervising personnel for future career goals may contribute to a sense of risk and perceived cost for speaking up. 13In addition, medical students may not be familiar with recommended communication techniques for hierarchical teams, such as crew resource management, as they are not often included in team training exercises.In this context, we describe a simulation curriculum that addresses this gap, in which students learn and practice skills necessary to communicate within a health care team to address observed lapses in professionalism within a framework of patient safety principles.By using the TeamSTEPPS tools, we sought to provide learners with effective communication strategies they could practice using to confront unprofessional behavior and minimize such behavior's impact on patient safety.
In developing this curriculum, we chose to appeal to students' sense of altruism, based on the theory of self-determination. 14his framework centers on intrinsic motivation, wherein learners engage in an activity out of genuine interest.It is associated with deeper learning, better performance, and improved wellbeing.Altruism is highly valued as a core component of intrinsic motivation by many medical students and physicians. 14,15In designing the simulation scenario, we consulted the literature in which professionalism is taught by defining expectations of observable behaviors, which then provides the basis for assessment, feedback, and determination of progress toward desired outcomes. 16,17Hundert and colleagues suggest roleplay as an effective tool for promoting ethical development in physicians. 18Following these principles, we sought to establish observable actions consistent with professional behavior norms for both students and faculty and used simulation-based roleplay as the pedagogical technique.We decided on team-based learning to leverage the concept of communities of practice derived from situated cognition theory. 19This model emphasizes the social aspect of learning, in which context and community influence learning and thinking.
The clinical clerkship year is recognized as a time when medical students' empathy and idealism regarding professionalism wane. 6,20,21This course was developed for implementation immediately prior to the clerkship year to influence students' perceptions and behaviors prior to witnessing unprofessional behaviors.Based on its efficacy for teaching professionalism, 18,22,23 simulation role-play was chosen as an effective pedagogic approach for learners at this stage. 23,24[26] To focus on the patient safety implications of lapses in professionalism, our simulation content replicated a commonly observed occurrence: a physician not calling for an interpreter when evaluating a patient with limited English proficiency (LEP).Patients with LEP have worse outcomes, lower patient satisfaction, and decreased quality of care when interpreters are not incorporated into the care team. 27Use of interpreters is a recognized standard in patient care and can serve as an expected and observable professional behavior.We designed a case in which a medical student could be reasonably expected to intervene to address a professionalism lapse within a hierarchical team.We created a case with a clear correct answer (obtaining an interpreter for a patient with LEP) to minimize any effect of asymmetrical knowledge or medical nuance that might inhibit speaking up.
Using patient safety and prevention of medical error as the centerpiece, we designed and implemented a novel simulationbased curriculum to introduce concepts of professionalism to preclinical medical students.9][30] To our knowledge, there are no published simulation curricula for teaching professionalism for medical students, and our curriculum addresses this gap.clerkships to the second year of medical school was staged to create a 6-month overlap of clerkship students from the prior curriculum (third-year students) and the new curriculum (second-year students).A needs assessment after the 6-month overlap asked clerkship directors to identify competency domains where students entering clinical clerkships after this shortened preclerkship curricular phase might need additional preparation.We identified recognition of professional behavior as an area requiring better preparation.Based on these data, we defined three goals for this simulation curriculum: 1. Provide students with knowledge of professional behavior expectations for themselves and health care team members.2. Give students tools for addressing observed lapses in professionalism by a team member in real time.3. Provide an opportunity to practice using those tools in a safe environment.
For complete case details, please refer to the simulation case summary (Appendix A).We developed the simulation with a flipped classroom model, including a narrated 25-minute slide set (Appendix B).The preclass material was available to the students up to 4 weeks prior to participation in the simulation.The simulation session, including orientation, role-play, and debriefing, lasted 45 minutes.The simulation was one of three stations in a simulation skills day offered weekly as part of a 4-week course in the month immediately prior to starting clinical clerkships.The skills day included a 25-minute orientation at the start of the day; students then completed the simulation and debrief in groups of four to five.We offered the curriculum in 2018 and 2019 and suspended the course in 2020 due to COVID-19 constraints on in-person gathering and staffing shortages.
The prerecorded lecture and slide set consisted of four sections.
In the first section, we reviewed definitions of professionalism and highlighted expected professional behaviors for clerkship students.Students were prompted to consider potential differences between their personal definitions of professionalism and the aspects of professionalism that residents and faculty might assess.The second section described qualities of successful teams, including shared goals, mutual support, and using the SBAR (situation, background, assessment, and recommendations) handoff tool as a common mnemonic for effective interprofessional communication. 32The third section introduced TeamSTEPPS, focusing on three techniques for conflict resolution: CUS words (I am concerned, I am uncomfortable, this is a patient safety issue), the DESC-ribe model (describe, express, suggest, consequences), and the two-challenge rule. 33We chose to emphasize these techniques for their utility in catalyzing effective communication within hierarchical teams that students might encounter in clerkship settings.The techniques provided junior team members with a patient safety-centered approach to challenging senior team members.This approach focused on behavior, rather than personal characteristics, which could be more effective in achieving desired behavioral change.The fourth section of the preclass material consisted of video vignettes demonstrating these techniques as possible responses to witnessed lapses in professionalism.

Equipment/Environment
The simulation took place in our institution's simulation center, utilizing a simulated single-bed hospital room with capacity for electronic vital signs display monitors and a one-way observation window.The role-play lasted approximately 7 minutes, followed by a 15-to 20-minute guided debriefing.Other equipment included a white coat and stethoscope for the attending physician.Each participant was randomly assigned a role as a member of the team and received a laminated card describing their role and their character's backstory (Appendix C).

Personnel
The personnel required for this simulation included an individual familiar with the function and roles of health care teams to play the role of attending as a standardized participant.Using an actual physician proved beneficial due to the need to understand the way teams make rounds and the role of a supervising attending.A second person served as timekeeper and observer.
In each session, the attending role was played by one of the authors.A member of the simulation center staff (one of two registered nurses) or the course administrator served as the observer.The observer interrupted the session with a knock on the door if the allotted time for a session had elapsed.The observer assisted in the debrief facilitation, as this individual monitored the team for nonverbal communications the attending may not have noticed.The observer remained behind the observation window during the simulation.

Implementation
For each skills day, participating faculty and simulation staff met for 5-10 minutes prior to the session to review the simulation, including timing, debrief checklist, and number of students participating.On the day of the session, one of the authors gave a brief, 20-minute review of the precourse material and a description of the role-play scenario as part of the skills day orientation.Students then participated in the simulation in groups of four to five, also taking part in other unrelated skills stations running in parallel.
At the time of the simulation, students received laminated roleassignment cards to read immediately prior to participation (Appendix C).A flowchart describing the simulation can be found in Appendix D. The roles included a new clerkship student, a subintern, an intern, a senior resident, and a patient.For groups of only four learners, we omitted the subintern role.The student playing the patient was instructed to wait in the room and read their role card.The faculty member escorted the remaining students to another room, instructed them to read their roles, and answered any questions.The student playing the role of the patient was briefed separately by the faculty member or observer.This student was instructed to act as a person who did not speak or understand English with enough proficiency to follow the group discussion.Importantly, this role did not require the student to speak or understand another language, merely to act as though they did not speak or understand English.The student was instructed to act as a reasonable person might, including trying to communicate with team members who might speak or understand their own language.All students were instructed that some roles in the scenario understood or spoke the patient's language and to interact accordingly.Faculty instructed learners to act as their character might during the simulation, and learners had access to their character cards for reference throughout.The faculty member playing the role of the attending reminded all students that the attending would display a lapse in professionalism and that student participants would have the opportunity to intervene.
The role-play began with the attending leading the team back into the room to round on the patient.The attending interacted with the patient using unidirectional communication, not recognizing the patient as LEP until learners intervened.The attending then used inappropriate means of communication (increasing speaking volume, miming, asking if a family member were available to translate, or using translation phone apps) and encouraged the participants to do so as well.The attending continued to interview and attempted to examine the patient until one or more learners used the complete set of communication tools or until the two-challenge rule was met.At that time, the attending agreed to call an interpreter before continuing with the patient encounter, and the scenario ended with the observer entering the room.The group moved to a debrief room where the faculty member and observer led the debrief.The debrief lasted 15-20 minutes and included learners' reflections and time for clarifying questions.The briefing and debriefing guides are in Appendix E.

Debriefing
The participating faculty member and observer conducted a short structured formal group debrief with all learners immediately following the simulation (Appendix E).The goals of the debrief were to ensure participant psychological safety, highlight the communication techniques used, and discuss successes and opportunities for improvement in team communication.First, we established learner well-being after the exercise.Second, we asked the participant playing the role of patient to describe their experience, followed by the other team members.A third component prompted self-reflection with the question "How do you think that went?"After a group reflection, the faculty member or observer reviewed when in the scenario the critical actions had occurred and how the team had communicated to the attending.Lastly, the participants had the opportunity to provide verbal feedback on the efficacy of the session.

Assessment
Learners completed the simulation session as a team, and thus, the critical actions checklist we developed (Appendix F) was limited to actions of the team.We developed a survey (Appendix G) to determine learners' acquisition and retention of knowledge, skills, and behaviors covering definitions of professional behavior and communication techniques (knowledge), use of communication techniques (skill), and whether they had employed any of those techniques (behavior).We conducted a literature search for similar instruments but did not identify one consistent with our specific objectives.We piloted the instrument among four postclerkship student volunteers who were not in the final respondent population and conducted cognitive interviews with one volunteer faculty member, revising the instrument after each round of input.Surveys used 5-point Likert scales and included free-text boxes for students to report personal experiences with observed lapses in professionalism.We administered baseline surveys 30 minutes before the simulation.Postsession surveys were administered immediately and at 6 months after the session.Surveys were distributed electronically and were voluntary and deidentified.
To link baseline and later surveys, respondents were asked to choose a personal identifier including the last four digits of their home phone number.For analysis of the data, the Likertscale options of strongly agree and agree were collapsed, and proportions were compared using the McNemar test.This project was initially approved as a pilot curriculum by the Harvard Medical School Office of Educational Quality Improvement and later was deemed an educational quality improvement project.

Results
In 2018 and 2019, 270 students were scheduled to attend the simulation as part of a transition to the clerkship year preparatory course.Of the 253 (94%) who attended, 179 started the baseline survey (71%), and 72 finished it (28%).Seventy students completed the immediate postsurvey (28%), and 39 completed a 6-month postsurvey (15%).Demographic characteristics are listed in Table 1.Students who completed the baseline survey were similar to those who completed the immediate and 6-month postsession surveys with regard to age, gender, and self-reported race/ethnicity.
Between baseline and immediate postsurveys, there was a significant increase in the percentage of students who reported knowing how to communicate about patient safety issues (82% to 94%, p = .003;Table 2).There also was a significant increase in the percentage who felt empowered to speak up to residents (19% to 44%, p = .001)and attendings (15% to 39%, p < .001).Moreover, there was a significant increase in the percentage who agreed they were expected to speak up when they observed a lapse in professionalism (67% to 80%, p = .02).The percentage who agreed they were expected to speak up when there was a patient safety issue did not increase significantly, though this was in the setting of a high percentage of this expectation at baseline (94% to 97%, p = .32).None of these gains persisted at the 6-month survey (Table 2).
Student satisfaction with the curriculum was high.One hundred thirty-five students (53%) completed course evaluations, of whom 100 (74%) rated the curriculum as excellent and 25 (18%) as good.Of 103 narrative comments for the entire 5-week course (62 in 2018, 41 in 2019), 39 mentioned this session (32 in 2018, seven in 2019), and all were positive comments.The prework Six months after the course, a majority of respondents reported they had learned either a moderate amount or a lot about the definition of professionalism (59%) and about how professionalism is assessed in clerkships (61%) from the simulation (Table 3).Overall, 70% of respondents reported satisfaction with the amount of training, 23% reported it was not enough, and 8% reported it was too much training.
In the 6-month postsurvey, 37 of 39 respondents (96%) reported witnessing a lapse of professionalism in their clerkships.Of these, 14% reported speaking up in response, using any of the techniques taught.

Discussion
We developed a simulation curriculum incorporating elements of role-play and flipped classroom to teach concepts of professionalism and communication tools for preclerkship students and found improvement in self-reported knowledge, empowerment, and understanding of expectations around speaking up about professionalism lapses.Not all improvements reached statistical significance, however.These gains did not persist at a 6-month follow-up.Our curriculum was well received, with course evaluation data indicating that over 90% of participants rated the exercise as an excellent or good contribution to their learning, while narrative comments were uniformly positive.Course evaluation data may be reflective of a wider sample of the participants than our survey responses, as the response rate was higher.
Our survey responses highlight the commonality of professionalism lapses witnessed by students, with 96% of respondents at 6 months reporting a witnessed lapse, consistent with published surveys. 34Our finding that only 14% reported using the strategies taught in the simulation is also consistent with the literature.In their study of student responses to professionalism breaches, Mak-van der Vossen and colleagues reported low numbers for the suggested response strategies of ignore, challenge individual, discuss with peers, or report. 4They that noted students chose to ignore lapses when they did not know how to respond and that, after avoiding a lapse, students without exception reported discussing the observed lapse with peers.The authors suggested that although students choose to ignore a lapse in the moment, they may be motivated to other action, such as seeking change in policies, commenting that "these student leaders are likely to be the future change agents the medical profession needs." 4 In our 6-month survey, 82% of respondents agreed they had learned new strategies to address lapses in professionalism.This suggests longer-term retention of these skills that students can employ in innovative, systems-level approaches to improving professionalism, as suggested by Lucey and Souba. 35r follow-up finding that most respondents chose not to address a professionalism lapse may be due to several causes.Perhaps a one-time intervention was insufficient to motivate action and additional interventions are needed to improve learners' confidence in and ability to address professionalism lapses.Another possibility is that the hierarchies of medicine or concerns about grades continue to inhibit student responses.Professional identity formation and concepts of professionalism begin prior to matriculation and evolve during medical school.Elements of the hidden curriculum include unspoken and untaught expectations regarding professional behavior. 18,33,36hese influences may have affected students' willingness to use the communication skills taught without affecting their acquisition of knowledge of the techniques.This is supported by the finding that students did report increased empowerment at the immediate postsurvey.Alternatively, students' low hierarchical status on clinical teams and their unique vulnerability as learners seeking positive evaluations may have affected their behavior. 37ore completely understanding the reason for this finding represents an opportunity for future studies.
The role-play included two unique roles: the patient and the attending.During our first iteration, the role of the patient was played by simulation center staff or a volunteer faculty member.This role requires the participant to pretend to have a limited understanding of English and all participants to engage in a suspension of disbelief.Students suggested the role could be played by a learner to help learners understand the patient experience.We found learners in this role routinely reported similar experiences of feeling excluded from the conversation.Sharing this experience with their peers anecdotally elicited empathy for patients with LEP and others who have difficulty communicating (e.g., individuals with deafness, developmental delay, or dementia).All learners shared their experiences in the debrief, allowing the entire group to benefit from the lessons learned by each participant.
We elected to use physicians for the attending role as it required a detailed understanding of how in-patient rounds occur and of the roles on the team.Concerns might be raised about having a member of the faculty participate in the role-play, in that learners could feel intimidated by working with a supervising physician and faculty member or that it may be disingenuous for the instructor to participate in the role-play as if unaware of the professionalism lapse acted out.Any role-play simulation requires participants to suspend disbelief.We believe using nonevaluative physicians contributes to the realism of the simulation; learners can practice skills in a realistic but safe setting with a faculty member giving feedback and suggestions for improvement.Additionally, the commonality of the professionalism lapse used in this simulation means most physicians can easily act out the role as they have most likely witnessed this lapse themselves.We do not believe either aspect adversely affected the learner experience or our results, and no participant comments indicated discomfort with faculty participation.The simulation can employ actors or nonphysicians as standardized participants for these roles if desired.
The group role-play exercise may have influenced the behavior of simulation participants.At our institution, preclerkship students learn almost exclusively in team settings, termed case-based collaborative learning. 31Team-based learning is a widely accepted pedagogical approach, and students are unlikely to feel inhibited in this setting. 38Additionally, the simulation reflects skills students need to work on interprofessional health care teams, fulfilling the Liaison Committee on Medical Education's stipulation for preparation to function on interprofessional teams. 39necdotally, students in the simulation frequently worked collaboratively to achieve the goal of calling the interpreter.
Our sample size of respondents was not powered for subgroup analysis based on demographic characteristics surveyed, including age, gender, and race or ethnicity.We did note trends toward gender and racial differences in responses, with male students and White students reporting a greater increase in their sense of empowerment to address professionalism and safety issues compared to female and non-White respondents.These findings reflect existing literature on the learning environment and call attention to the need to address microaggressions and discrimination in the clinical learning environment.Students from groups underrepresented in medicine report less supportive and less positive learning environments. 34,40Our finding of greater increase in empowerment in male and White students may reflect a more supportive learning environment for these students.
Our project has several limitations.An important limitation is the low response rate, particularly for the immediate postsurvey and 6-month postsurvey, despite electronic administration easily completed on handheld devices and multiple email reminders.
The surveys were lengthy, which may have caused survey fatigue, contributing to the low response rate.Our small sample size limited power to assess differences based on characteristics such as gender, race, and ethnicity.Other limitations include several types of bias that may have occurred.The wording of the follow-up survey may have introduced recall bias.The high percentage of respondents who reported witnessing lapses in professional behavior (over 95% of respondents) may reflect a halo effect: Students who had witnessed lapses may have been more likely to complete the follow-up survey.We do not have details about the nature of professionalism lapses observed or which clerkships students had completed at the time of the 6-month survey.We are thus unable to determine the effect of specific clerkships on response rate, witnessed professionalism lapses, or speaking up.We queried satisfaction and self-assessment of learning, which are inherently limited by students' relative lack of experience and context in which to evaluate the curriculum.Lastly, we intended to gather data in the subsequent academic years; however, due to COVID-19 restrictions, the curriculum was not implemented.We thus report data from the 2 years of implementation.
Several changes may improve future iterations of this educational intervention.Students reported an increase in knowledge immediately after the exercise, and repeated exposure to similar curricula may be needed to effect behavior change or change the learning environment.Learners may benefit from repetitive practice of team communication skills, and subsequent simulations may reinforce these skills.The curriculum is adaptable to an online or remote synchronous platform using videoconferencing.This adaptation would require no significant changes to the material or the role-play exercise and could be employed for distance learning by institutions with learners at multiple sites.
This role-play simulation curriculum provides training and practice in interpersonal communication skills for medical students for use in the complex and often hierarchical patient care teams encountered in clerkships.Using a commonly encountered lapse in professionalism and focusing on patient safety, we demonstrated immediate improvement in knowledge and empowerment to engage in difficult conversations within a team.

Table 1 .
Respondent Characteristics had 473 viewings with 311 unique users, of whom 203 viewed once, 79 viewed twice, and 16 viewed three times.
a Responses were limited to binary or prefer not to answer.video

Table 2 .
Responses of Strongly Agree or Agree on the Presession and Immediate Postsession Surveys Percentages on this item do not add up to 100% due to incomplete responses. a